For the last three years, I have been asking my patients at their annual physical visit the following question: “What are your health goals for the coming year?” I follow up with: “What do you need to achieve them,” or “What would get in the way?” These questions, which seem logical when we stress patient-centered health care, patient empowerment, and lifestyle choices as the major determinants of health, seem to reach many of my patients’ ears as an enunciation in a foreign language. The startling, “What?” was the first answer of many, followed by, “I don’t know.” Alternatively, the response might be, “What do you mean? I thought you were going to examine me.” Then the true conversation started.
Establishing health goals is one of the most powerful practices at a yearly preventive visit. It allows patients and physicians to work as a team examining patients’ current state of health– their capabilities, strengths, resources, weaknesses, deficiencies, lost skills, and longings in their personal, work, and relational spheres. This foundation allows patients to identify the aspects of their life they want to improve or what they want more of, leading to establishing strategies to achieve their objectives. The physician acts as a coach, eliciting possible obstacles and opportunities, and helping the patient set a map on navigating them.
When I put this exercise into practice, I was bemused by how most of my patients would reply that their health goal for the coming year was to lose weight. Even the thin and fit gave me the same answer. Though a good practice, weight loss per se is not a goal. Weight loss, I explained to my patients, only means they’ve become lighter, which in itself achieves nothing. It was turning the conversation to “What would you achieve being lighter that you cannot do now,” or, “How would being lighter make you a better person than what you are now?” That’s where true goal setting started. Goals became, “Next year I’ll be able to walk around the block without getting short of breath,” or, “Next year I’ll be able to get to the floor and play with my kids,” or, “Next year I will have the energy to endure the day without naps.” There was also the hidden value to weight loss I often had to elicit because no one wanted to bring it up: losing weight to look good, to feel attractive, to fit in a bathing suit and go swimming, to disrobe in front of the loved one in plain light, or to make love. To me, that conversation is more relevant than asserting that their lungs are clear to auscultation and that their hearts have regular rate and rhythm.
The conversation about goals doesn’t end with physical capabilities, though. I always had to add, “And what about your sleep?” The answer many times was, “Oh, my sleep is awful!” My response was to add, “Don’t you want to make restful sleep a health goal for the next year? And what about your relationships, your community participation, and your work? Don’t you want to be taking fewer medications by next year?” All those are part of what determines our state of health. Their health goals and the notes I took about them were printed with their visit summary.
I never thought that the objective of this practice was to obtain measurable outcomes. In fact, most patients didn’t achieve what they set to accomplish. We discussed previous years’ goals the following year not as a platform for judgment and shame, but to again discuss what is important in their lives. In many cases, weight loss was no longer a goal, as they had moved to other purposes that represented a higher value to them. What the exercise meant to me was the opportunity to center the discussion on what really matters to patients. What their core values are. What meaning they place on their capabilities and frailties, and what they are willing to do to use them or conquer them to achieve better health.
Yearly physicals are usually afforded a longer time than regular visits. If I can use most of that time focusing the discussion on what a healthy life means to each of my patients and what they need to achieve it, I feel that I’ve accomplished more than doing palpation, range of motion, and auscultation. Discussing medications and finding opportunities for de-prescribing, and discussing annual routine labs’ futility is also an equally important and welcome part of my yearly rituals. As our population ages and we are faced with more chronic diseases, our goal is to maximize our patients’ abilities to function, relate to family and community, and live a life of purpose. Expanding the visit to discuss health status, strengths, weaknesses, and goals is a good time investment in achieving healthier people and enriching our relationship with patients. For my part, it also adds joy and purpose to my life.
Alina Urriola is a family physician.
Image credit: Alina Urriola
